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Advanced Trauma Life Support, 8th Edition, The Evidence for Change

Volume 64(6). June 2008.1638-1650


http://decode-medicine.blogspot.com/ summarized by sun yaicheng

ATLS 8e Compendium of Changes

History

The ATLS course for doctors was introduced in Nebraska in 1978. It was adopted by the American College of Surgeons and was rapidly introduced across North America in the early 1980s.

Doctor James K. Styner

ATLS 8e Compendium of Changes

ATLS Program Overview

Access the patients condition rapidly and accurately. Resuscitate and stabilize the patient according to priority. Determine if the patients needs exceed a facilitys capacity. Arrange appropriately for the patients inter-hospital transfer (who, what, when, and how). Assure that optimum care is provided and that the level of care does not deteriorate at any point during the evaluation, resuscitation, or transfer process.

ATLS 8e Compendium of Changes A Brief Summary of Wright et al. Levels of Evidence. JBJS(A)
Treatment Prognosis Diagnosis Economic and Decision analysis

Level of Evidence
1 RCT with significant difference or narrow confidence intervals Systematic reviews of level 1 studies 2 Prospective cohort, poor quality RCT Prospective study with single inception cohort and 80% follow-up Systematic review of level 1 studies Retrospective study, untreated controls from a previous RCT Systematic review of level 2 studies Testing of previously applied diagnostic criteria in a consecutive series against a gold standard Systematic review of level 1 studies Development of diagnostic criteria on basis of consecutive patients against a gold standard Systematic review of level 2 studies Study of nonconsecutive patients (no consistently applied gold standard) Clinically sensible costs and alternatives; values obtained from many studies; multiway sensitivity analyses Systematic review of level 1 studies Clinically sensible costs and alternatives, values cobtained from limited studies, multiway sensitivity analyses Systematic review of level 2 studies Limited alternatives and costs; poor estimates

Systematic reviews of level 2 studies 3 Casecontrol study

Retrospective cohort study Systematic review of level 3 studies 4 5 Case series Expert opinion Case series Expert opinion Systematic review of level 3 studies Casecontrol study Poor reference standard Expert opinion Systematic review of level 3 studies No sensitivity analyses Expert opinion

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Initial assessment

ATLS 8e Compendium of Changes

Rectal examination
7th Edition A rectal examination should be performed before inserting a urinary catheter
8th Edition A rectal examination should be performed selectively before placing a urinary catheter. If the rectal examination is required the doctor should assess for the presence of blood within the bowel lumen, a highriding prostate, the presence of pelvic fractures, the integrity of the rectal wall, and the quality of the sphincter tone.

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Airway

ATLS 8e Compendium of Changes

Carbon dioxide detectors


7th Edition A CO2 detector (colorimetric CO2 monitoring device) is indicated to help confirm proper intubation
8th Edition A CO2 detector (ideally capnography but if not available by a colorimetric CO2 monitoring device) is indicated to help confirm proper intubation of the airway

ATLS 8e Compendium of Changes

Laryngeal mask airway (LMA)


7th Edition

The LMAs role in the resuscitation of the injured patient has not been defined

8th Edition

There is an established role for the LMA in the management of a patient with a difficult airway, particularly if attempts at tracheal intubation or bag-valve-mask ventilation have failed. The LMA does not provide a definitive airway. When a patient has an LMA in place on arrival in the emergency department, the doctor must plan for definitive airway.

ATLS 8e Compendium of Changes

Laryngeal tube airway (LTA)


7th Edition New material 8th Edition The LTA is an extraglottic airway device with similar capability to provide successful ventilation to the patient as that of the LMA. The LTA is not a definitive airway device and plans to provide a definitive airway must be implemented.

ATLS 8e Compendium of Changes

Gum Elastic Bougie


7th Edition New Material
8th Edition An useful tool when faced with the difficult airway is the Eschmann tracheal tube introducer (ETTI) also known as the gum elastic bougie (GEB). It is a 60 cm long, 15 French intubating stylette. The ETTI is employed when vocal cords cannot be visualized on direct laryngoscopy. In multiple operating room studies, successful intubation is seen at rates greater than 95% with ETTI. In cases where potential cervical spine injury is suspected, ETTIaided intubation was successful in 100% of cases in less than 45s . This simple device allowed rapid intubation of nearly 80% of prehospital patients with difficult direct laryngoscopy.

ATLS 8e Compendium of Changes

Difficult airway
7th Edition New material
8th Edition It is important to assess the patients airway before attempting intubation to predict the likely difficulty. Factors which may predict difficulties with airway maneuvers include significant maxillofacial trauma, limited mouth opening and anatomical variation such as receding chin, overbite, or a short thick neck. The mnemonic LEMON (look, evaluate, mallampatti, obstruction, neck) is helpful as a prompt when assessing the potential for difficulty.

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Shock

ATLS 8e Compendium of Changes

Crystalloid
7th Edition Warmed isotonic electrolyte solutions are used for initial resuscitation. Lactate ringers (RL) is the initial fluid of choice. Normal saline is the second choice.
8th Edition Warmed isotonic electrolyte solutions (eg RL or normal saline), are used for initial resuscitation. An alternative initial fluid is hypertonic saline although current literature does not demonstrate any survival advantage.

ATLS 8e Compendium of Changes

Fluid resuscitation
7th Edition Initial fluid resuscitation based on the 4 ATLS classes of hemorrhage is presented. Assess the patients response to fluid resuscitation and evidence of adequate end organ perfusion

ATLS 8e Compendium of Changes

Fluid resuscitation
8th Edition

The goal of resuscitation is to restore organ perfusion. This is accomplished by the use of resuscitation fluids, and has been guided by the goal of restoring a normal blood pressure. It has been emphasized that if blood pressure is raised rapidly before the hemorrhage has been definitely controlled, increased bleeding may occur. Persistent infusion of large volumes of fluids in an attempt to achieve a normal blood pressure is not a substitute for definitive control of bleeding. Fluid resuscitation and avoidance of hypotension are important principles in the initial management of blunt trauma patients particularly with TBI.

ATLS 8e Compendium of Changes

Fluid resuscitation
8th Edition

In penetrating trauma with hemorrhage, delaying aggressive fluid resuscitation until definitive control may prevent additional bleeding. Although complications associated with resuscitation injury are undesirable, the alternative of exsanguination is even less so. Balancing the goal of organ perfusion with the risks of rebleeding by accepting a lower than normal blood pressure has been called Controlled resuscitation, Balanced Resuscitation, Hypotensive Resuscitation and Permissive Hypotension. The goal is the balance, not the hypotension. Such a resuscitation strategy may be a bridge to but is also not a substitute for definitive surgical control of bleeding.

Angio-embolization and definitive control of hemorrhage

ATLS 8e Compendium of Changes

7th Edition Angio-embolization described for hemodynamically abnormal pelvic fractures with negative DPL
8th Edition Failure to respond to crystalloid and blood administration in ED dictates the need for immediate definitive intervention to control exsanguinating hemorrhage, (e.g. operation or angioembolization)

ATLS 8e Compendium of Changes

Treatment of cardiac tamponade


7th Edition Pericardiocentesis is the initial management of traumatic tamponade
8th Edition Acute cardiac tamponade due to trauma is best managed by thoracotomy. Pericardiocentesis may be used as a temporizing maneuver when thoracotomy is not an available option

ATLS 8e Compendium of Changes

Base deficit & lactate


7th Edition Base deficit may be useful in determining the severity of the acute perfusion deficit
8th Edition Base deficit and/or lactate can be useful in determining the presence and severity of shock. Serial measurement of these parameters can be used to monitor the response to therapy

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Thoracic trauma

ATLS 8e Compendium of Changes

Treatment of pneumothorax
7th Edition Observation and/or aspiration of a pneumothorax are risky
8th Edition A pneumothorax is best treated with a chest tube in the 4th or 5th intercostal space, just anterior to the midaxillary line. Observation and/or aspiration of an asymptomatic pneumothorax should be determined by a qualified physician, otherwise placement of chest tube should be performed

ATLS 8e Compendium of Changes

ED thoracotomy
7th Edition Penetrating thoracic trauma patients, who arrive pulseless with electrical activity may be candidates for resuscitative thoracotomy (RT). Patients sustaining blunt injuries who arrive pulseless with myocardial electrical activity are not candidates for RT

ATLS 8e Compendium of Changes

ED thoracotomy
8th Edition

A patient sustaining a penetrating wound, who has required CPR in the prehospital setting should be evaluated for any signs of life*. If there are none and no cardiac electrical activity is present, no further resuscitative effort should be made.
* The recommendation on ED thoracotomy includes a review of signs of life for penetrating trauma (reactive pupils, spontaneous movement, organized EKG activity).

Patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity (PEA) are not candidates for resuscitative thoracotomy (RT).

ATLS 8e Compendium of Changes

Blunt traumatic aortic injury


7th Edition New material 8th Edition Techniques of endovascular repair are rapidly evolving as an alternate approach for surgical repair of blunt traumatic aortic injury.

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Abdomen

ATLS 8e Compendium of Changes

Explosive devices
7th Edition New Material 8th Edition Explosive devices cause injuries through several mechanisms. These include penetrating fragment wounds and blunt injuries from the patient being thrown or struck. Patients close to the source of the explosion may have additional pulmonary or hollow viscus injuries related to blast pressure which may have delayed presentation.

ATLS 8e Compendium of Changes

Hemo-dynamically abnormal pelvic fractures


7th Edition

Describes management based on DPL+ (celiotomy) and DPL (angiography-embolization)

8th Edition

The pelvis should be temporarily stabilized or closed using an available commercial compression device or sheet to decrease bleeding. Intraabdominal sources of hemorrhage must be excluded or treated operatively. Further decisions to control ongoing pelvic bleeding include angiographic embolization, surgical stabilization, or direct surgical control.

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Head trauma

ATLS 8e Compendium of Changes

Classification and head CT


7th Edition

Mild brain injury defined as GCS 1415. CT is ideal in all patients except completely asymptomatic and neurologically normal

8th Edition

The categorization of traumatic brain injury reflects a continuum. The definition of minor traumatic brain injury has reverted to GCS 1315, with moderate changed to 912. The Canadian CT Head Rule has been adopted as a guide to clarifying when CT scans of the head should be used.

ATLS 8e Compendium of Changes

Canadian CT Head Rule for patients with minor head injury

Failure to reach GCS of 15 within 2 h Suspected open or depressed skull fracture Any sign of basal skull fracture (haemotympanum, racoon eyes, cerebrospinal fluid otorrhoea/rhinorrhoea, Battle's sign) Vomiting >2 episodes Age >65 years Amnesia before impact >30 min Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or 5 stairs)
Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 1315

Lancet. 2001 May 5;357(9266):1391-6.

ATLS 8e Compendium of Changes

Penetrating brain injury


7th Edition New material 8th Edition Objects that penetrate the intracranial compartment or infratemporal fossa must be left in place until possible vascular injury has been evaluated and definitive neurosurgical management is established. Disturbing or removing penetrating objects prematurely may lead to fatal vascular injury or ICH.

ATLS 8e Compendium of Changes

Penetrating brain injury


8th Edition

More extensive wounds with nonviable scalp, bone, or dura are treated with careful debridement before primary closure or grafting to secure a watertight wound. Significant mass effect is addressed by evacuating intracranial hematomas, and debridement of necrotic brain tissue and safely accessible bone fragments. In the absence of significant mass effect, surgical debridement of the missile track in the brain, routine surgical removal of fragments distant from the entry site and reoperation solely to remove retained bone or missile fragments does not measurably improve outcome and is not recommended.

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Spine

ATLS 8e Compendium of Changes

Blunt carotid and vertebral vascular injuries (BCVI)


7th Edition

New material

8th Edition

Blunt trauma to the head and neck has been recognized as a risk factor for carotid and vertebral arterial injuries. Early recognition and treatment of these injuries may reduce the risk of stroke. Suggested criteria for screening include:
a) C13 fracture b) C spine fracture with subluxation c) Fractures involving the foramun transversarium.

Approximately 1/3 of these patients will have BCVI when imaged with CT angiography of the neck

ATLS 8e Compendium of Changes

Steroids
7th Edition In North America high dose methyprednisolone given to the patient with nonpenetrating spinal cord injury . . . is a currently accepted treatment
8th Edition There is insufficient evidence to support the routine use of steroids in spinal cord injury at present.

ATLS 8e Compendium of Changes

CT evaluation of the cervical spine


7th Edition New material 8th Edition CT may be used in lieu of plain images to evaluate the C Spine.

ATLS 8e Compendium of Changes

Atlantooccipital dislocation
7th Edition New material 8th Edition Aids to identification of atlanto-occipital dislocation on spine films including Powers ratio are included in the spinal skills station.
Power's Ratio: A = C1 anterior arch, B = basion (anterior margin of foramen magnum), C = anterior portion of the posterior ring of C1, O = opsthion (posterior margin of foramen magnum). If BC/AO greater than 1, anterior occipitoatlantal dislocation exists.

Powers ratio to diagnose AOD shown on plain radiographs and CT scans of a patient without injury

ATLS 8e Compendium of Changes

From: Dziurzynski: Spine, Volume 30(12). June 15, 2005.1427-1432

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Musculoskeletal trauma and extremity trauma

ATLS 8e Compendium of Changes

Tourniquet
7th Edition

The judicious use of a pneumatic tourniquet may be helpful and lifesaving

8th Edition

The use of a tourniquet while controversial may occasionally be life and/or limb saving in the presence of ongoing hemorrhage uncontrolled by direct pressure. A tourniquet must occlude arterial inflow, as occluding only the venous system can increase hemorrhage. The risks of tourniquet use increase with time. If a tourniquet must remain in place for a prolonged period to save a life, the physician must be clear that the choice of life over limb has been made.

ATLS 8e Compendium of Changes

Compartment syndrome
7th Edition A palpable distal pulse usually is present in compartment syndrome
8th Edition Absence of a palpable distal pulse usually is an uncommon finding and should not be relied upon to diagnose a compartment syndrome. Early findings of compartment syndrome are emphasized in the text

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Trauma in women

ATLS 8e Compendium of Changes

Restraints
7th Edition New material 8th Edition Compared with restrained pregnant women involved in collisions, unrestrained pregnant women have a higher risk of premature delivery and fetal death.

ATLS 8e Compendium of Changes

Airbags
7th Edition New material 8th Edition There does not appear to be any increase in pregnancy-specific risks from deployment of airbags in motor vehicles.

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Pediatric trauma

ATLS 8e Compendium of Changes

Functional outcome
7th Edition New material 8th Edition Long-term follow-up of functional outcome indicates that while victims of major trauma during childhood may retain functional disabilities, quality of life remains very high.

ATLS 8e Compendium of Changes

Abdominal imaging CT
7th Edition New material 8th Edition The presence of a splenic blush on CT with intravenous contrast does not mandate exploration, and the decision to operate continues to be based on the amount of blood lost as well as abnormal physiologic parameters.

ATLS 8e Compendium of Changes

Abdominal imaging FAST


7th Edition

The role of abdominal ultrasound in children with abdominal injury remains to be defined

8th Edition

If large amounts of intraabdominal blood are found, significant injury is certain to be present. However, operative management is indicated not by the amount of intraperitoneal blood, but by hemodynamic abnormality and its response to treatment. FAST is incapable of identifying isolated intraparenchymal injuries, which account for up to 1/3 of solid organ injuries in children.

ATLS 8e Compendium of Changes

Abdominal bruising
7th Edition New material 8th Edition The incidence of intraabdominal injury is significantly higher if abdominal wall bruising is observed during the primary or secondary survey.